Abstract

The understanding and management of Peyronie's disease (PD) has improved but elucidating the exact etiology of the disease has yet to be achieved. In this paper, we review the historical and clinical aspects of PD. We focus on the evolution of surgical management for PD and review recent published articles that compare popular surgical techniques such as plication and plaque incision with vein graft. These two techniques have been reported to be equivalent with respect to patient satisfaction; however, each technique has its own advantages and disadvantages.

1. Introduction

Peyronie's disease (PD) was named after the French physician
Francois de la Peyronie in 1741. His original description was one of the fibrous
cavernositis “preventing them from having normal ejaculation of semen” [1]. The disease is currently thought to affect
between 3 and 9% of adult men, typically in the fifth to sixth decades of life.
Overall, its prevalence appears to be rising, though this may be due to the
fact that more men are seeking treatment for erectile dysfunction [2].

2. Pathophysiology

Despite a volume of basic science and clinical research, much
remains unknown about the etiology and ideal management of the disease. PD is a
localized connective tissue disorder of the penis leading to fibrosis,
scarring, and noncompliance of the tunica albuginea. One etiologic theory is
that the root cause of the fibrosis is ischemia and inflammation from repeated
penile trauma or microtrauma from activities such as sexual intercourse. The
resulting microvascular tears in this region lead to collagen deposition in the
form of plaques [3].

Some studies have suggested a link between PD and methotrexate,
while others have shown a genetic predisposition to the disease due to an
association with Dupuytren's contracture and with HLA-B7 and HLA-B27 antigens.
Still other authors have identified circulating antibodies that may point to a
possible immunologic cause of PD [4–7].

3. Clinical Presentation

Patients typically present with three, occasionally
simultaneous, chief complaints: a palpable plaque, a painful erection, and/or
penile curvature. Penile curvature can in fact be so severe in that it
interferes with the ability to engage in sexual intercourse (Figure 1). The
disease undergoes a transition between two phases: an acute inflammatory phase
and a chronic phase. Painful erections, developing penile curvature and nodule
formation mark the acute inflammatory phase. This phase is self-limiting,
typically lasting between six and eighteen months. Because the disease is
evolving during this phase, the patient's pain, the degree of curvature, and
the size of the plaque may also undergo change. The chronic phase is
characterized by minimal or no pain with stable nodule size and degree of
penile deformity [8].

Figure 1: Penile deformity secondary to Peyronie's disease.

4. Treatment

A variety of medical (i.e., nonsurgical)
treatments with isolated reports of treatment “successes” have been published,
but none have been substantiated in a randomized controlled fashion [9]. A thorough review of these therapies is
beyond the scope of this article.

Surgical techniques for correcting the penile deformity from PD
all share the same goals: correcting the curvature, preserving erectile
function and penile length, and minimizing morbidity. For men with good
erectile function, two main surgical concepts have been popularized: (1)
lengthening the concave contracted side using a graft (with or without plaque
incision/excision), and (2) shortening the convex, noncontracted side using
tunical excision or plication. For men with poor erectile function and
curvature, placement of a penile prosthesis to correct the erectile function
can be sufficient if the degree of curvature is mild. If the curvature is more
severe, a combination of one of the two approaches above with prosthesis
placement is the preferred method of surgical repair.

4.1. The Nesbit Procedure

The original tunical shortening procedure—the Nesbit procedure
(named after the surgeon who first described it)—was initially applied to
those with congenital penile curvature and later used for PD [10]. The
method involved excising an ellipse of tunica on the side opposite the
curvature, thereby straightening the penis. Though Nesbit's concepts have
helped to guide the other surgical techniques, the Nesbit procedure itself is fraught with complications including penile
shortening, recurrence of curvature, cavernous tissue herniation, and erectile
dysfunction [11]. The Nesbit procedure is increasingly being replaced
by one of the two surgical techniques described below.

4.2. Penile Plication

Initially introduced by Essed and Schroeder as a less-invasive
surgical option for PD, penile plication involves shortening the convex side of
the curvature without excising the tunica (Figure 2) [12]. Lue expanded on this procedure by describing
his “16 dot” technique that is rapid, involves no dissection of the
neurovascular bundles or the urethra, spares the patient from tunical incision
or excision, and reliably results in a straight penis in the appropriately
selected patient. The procedure may be done with less potential morbidity to
the patient under local anesthesia [13]. The relatively straightforward
nature of the procedure, however, is balanced by its limited applicability to
PD patients. Patients with bottleneck deformities, hourglass deformities, or
lateral indentations are not appropriately treated with plication; in fact, the
procedure is almost exclusively applicable to patients with simple curvature.
It is the authors’ experience, however, that the majority of patients with PD
fit into this category.

Figure 2: Correction of Peyronie's with corporeal plication.

Penile plication is associated with a number of well-described
potential drawbacks that should be discussed in full detail with the patient.
First, penile shortening has been reported from 41 to 90% of the time and is
indeed the major drawback for most PD patients. PD patients with severe
contraction may thus not be ideal candidates for plication; however, these
patients often have an element of erectile dysfunction and may be better suited
for receiving a penile implant. Second, sexual or erectile dysfunction
associated with plication has been reported anywhere from 7 to 40% of the time
in various studies. Other potential drawbacks described in previous studies
include loss of penile sensation in 3–48% of patients and permanent palpable
knots reported as “bothersome” in 12–18% of patients [13–16].

A study from 2007 reported patient-perceived outcomes from the
plication procedure in 57 patients who had undergone the penile plication
procedure for PD over a 10 year period [17]. With a median follow-up of
51 months, 90% reported a satisfactory cosmetic result, though only 71% reported
a satisfactory functional result defined as a “straight or almost straight
penis on erection with pain-free penetration and normal sexual intercourse.” Interestingly,
the subset analysis of long-term patients pointed to excellent subjective
durability of the plication procedure. 82%
of these patients reported satisfactory cosmesis and 71% reported functional
satisfaction. No objective data is
presented, but, in our opinion, patient-perceived outcomes on the success,
especially functionally, of the procedure should be of paramount importance
when describing the outcomes of the procedure.

4.3. Plaque Incision/Excision with Grafting

Conceptually, plaque incision or excision with venous grafting
approaches the contralateral aspect of the curvature—the concave side—with
the aim to lengthen the curvature on that contracted side (Figure 3). Both
incision and excision of the plaque with grafting have been described with similar
results, but no studies have compared results from the two procedures. Additionally, the use of both autologous and
synthetic grafts have been described, with the synthetic grafts reported as
being less elastic with a potential predisposition toward wound infection [18].
Similar to the intracorporeal space, venous grafts are lined by vascular endothelium
and are, therefore, theoretically more physiologic than other autologous
tissues. Additionally, venous grafts provide excellent elasticity and
durability. We prefer to use saphenous vein grafting because it is easy to
harvest, reliably provides sufficient length and width, and is associated with
little morbidity during harvest [19].

Figure 3: With the neurovascular bundles retracted
laterally by the vessel loops, an H-incision is made at the point of maximal curvature.

Side effects and complications of vein grafting procedures have
also been well described. Initial results from the procedure have always been
promising, with excellent patient satisfaction (86–92%) and high rates of
penile straightening (59–96%) in the first 12 months. A recent study involving
70 patients treated with plaque incision with venous grafting with a mean
follow-up of 41.7 months reported 53/70 patients (75.7%) with “completely
straightened” penile curvature. Of the remaining patients, 12.8% had residual
curvature less than 20 degrees and the remaining 11.4% had curvature more than
20 degrees [20]. Interestingly,
the lack of durability of the results has led to a more cautious consideration
of the applicability of tunical lengthening procedures in the urological
community. Two studies presenting five-year follow-up data reported a lack of
durability of the initial promising results with vein grafting. The first study
identified a significant decrease in patient satisfaction due to either
erectile dysfunction (22.5%) or penile shortening (35%) while the second study
reported overall satisfaction falling from 86% initially to 60% at five years [21, 22].
One of the reasons cited in the latter study for a decrease in satisfaction was
a subjective loss of penile length occurring in all of
the patients at five years. Theoretically, tunical lengthening procedures
should actually prevent or improve the penile shortening often associated with
PD, but many men nonetheless complained of a reduction in penile length.
Objective data from the same institution with 32 months of follow-up reported
no change in mean pre-versus postoperative penile length, despite a
patient-reported shortening in 40% of this group [23].

Clearly, the objective and patient reported assessment of penile
length is incongruous, which should be considered when counseling patients on
the “tunical lengthening” procedures.
Additionally, the reported long-term results of the procedure have led
to some skepticism in the urologic community about the durability of the
procedure, which should be conveyed to the patient when describing the
long-term outcomes.

4.4. Penile Plication versus Plaque Incision with Vein Grafting

A recent study from our institution compared subjective patient
reported experiences of tunical plication procedures () with plaque
incision and saphenous vein grafting procedures () at one year of follow-up [24].
The short interval of follow-up is not ideal, especially with the questionable
durability as described above, but nonetheless the results of our study are
compelling. There were no statistically significant differences between the two
groups with respect to straightening, overall patient satisfaction, erectile
pain, and penile shortening. Patients who underwent plication were more likely
to experience palpable sutures postoperatively but only 14% of patients
reported this to be of a significant concern. Patients who underwent plaque
incision with vein grafting were more likely to experience a loss in sensation
as well as a loss in erectile rigidity. They were also more likely to be unable
to have intercourse. Not surprisingly, the principle reason for the inability
to have intercourse postoperatively was due to the loss in erectile rigidity.
Loss in sensation was a significant patient concern in about one third of
patients when it did occur. Length of operative times for the two groups varied
drastically with an average time of 71 minutes for the plication group versus
an average time of 234 minutes for the plaque incision and vein grafting group
().

Based on the results of our study and the literature, at our
institution we currently offer both procedures to patients with simple
curvature secondary to PD. The
literature has not clearly shown an advantage of one technique over the other
in terms of long-term functional or cosmetic results. Indeed, recent literature has even pointed to
a relative lack of functional durability of the vein grafting technique
relative to plication, though this has never been demonstrated in a clinical
trial or with objective data. All of
this, as well as a description of the surgical technique, is described in
detail when counseling patients pre-operatively.

In patients with more complex anatomic abnormalities due to PD
(hourglass deformities, bottleneck deformities, or lateral indentations), we do
not offer plication. These patients can
clearly not be adequately treated with plication and require more extensive reconstructive
and grafting technique.

5. Conclusion

The understanding and management of Peyronie's disease has been
challenging but is improving. In reviewing the evolution of the surgical
treatments, various refinements have evolved. This evolution has not led to one
ideal surgical procedure which corrects all cases of PD, but rather there now
exist a repertoire of surgical techniques that can be offered by urologists and
selectively utilized for each individual's deformity. The surgical management
of PD should always involve patient counseling of the different operative
approaches and additionally should emphasize how these approaches will best
meet patients’ expectations. Being informed of the advantages and disadvantages
of each surgical technique, patients are better able to make an informed
decision.

F. Montorsi, A. Salonia, A Briganti, et al., “Five year follow up of plaque incision and vein grafting for Peyronie's disease,” in Proceedings of the Annual Meeting of the American Urologic Association, San Francisco, Calif, USA, May 2004.